Testimony

Statement byRichard H. Carmona, M.D., M.P.H., F.A.C.S.,
Surgeon General
U.S. Public Health Service
Department of Health and Human Services
on"Ageism in Healthcare: Are Our Nation's Seniors Receiving Proper Oral Health Care?"
before theSpecial Committee on Aging, United States Senate

September 22, 2003

Good afternoon Mr. Chairman and distinguished members of the Committee. My name is Dr. Richard Carmona, and I am the Surgeon General of the United States.

As an American, I want to take this opportunity to thank you for your service to our nation. I've had the honor of working with many of you during my first year as Surgeon General, and I look forward to strengthening our partnerships to improve the health and well-being of all Americans.

When I speak to people all over America, I tell them "we can't go it alone." As Secretary Thompson says, "we have to get out of our silos and sectors and work together."

It takes partnerships to solve public health problems. That is certainly the case for disease prevention, emergency preparedness, and eliminating health disparities, all priorities on which President Bush and Secretary Thompson have asked me to focus. It is also the case for making sure that we maintain and improve our oral health.

The burden of oral infections and conditions that affect the mouth, face and jaw are so broad and extensive that the dentists can't do it alone; the hygienists can't do it alone; surgeons can't do it alone; educators can't do it alone; government can't do it alone. It will take all of us working together to continue to make progress in advancing the oral health of all Americans.

Today, more than 75% of our health care dollars are spent on chronic diseases and conditions that are largely preventable — diabetes, obesity, heart disease, stroke, and cancer.

We are a treatment-oriented society. We wait for people to get sick and then we spend top dollar to make them healthy again.

We need your help to bridge the cultural divide … from a treatment-oriented society to one that is prevention oriented. My purpose here today is to encourage each of you to determine what you can do to promote oral health and prevent oral disease.

While oral health is tremendously important to all Americans, I'm sure I don't have to tell you that it is not always the focus of much attention. Americans tend to think that oral health is less important than, and separate from, general health.

But we must remember that the mouth is essential for so many of the day's activities, like talking, eating and breathing. I sincerely appreciate the focus of this forum today, especially in the context of a holistic prevention approach. Let's face it, prevention starts with the head.

Studies tell us that toothache and craniofacial disorders are common among American adults. Twenty-two (22%) percent of adults in our nation reported some form of oral-facial pain in the past six months. And oral and pharyngeal cancers, primarily found in the elderly, are diagnosed in about 30,000 Americans annually. Eight-thousand (8,000) people die from these diseases each year.

Poor oral health adversely affects all aspects of life. Kids can't learn in school if they are in pain. Adults lose work hours due to dental pain and tooth and gum decay.

The findings of the science-based report, Oral Health in America: A Report of the Surgeon General recognized that oral health is essential to general health and well-being. This integral relationship is demonstrated by the fact that oral diseases in and of themselves affect health throughout life and that general health problems, such as diabetes, osteoporosis, HIV, and other conditions, are associated with oral manifestations and effects. In addition, this report highlights the fact that low-income individuals have a higher prevalence of untreated oral diseases regardless of age.

Seniors, by the nature of their life span, are more prone to chronic, disabling diseases and conditions; are more apt to be on regimens of daily medications; and have a greater likelihood to be low-income than other adults. These factors and others have a profound affect on their oral health.

The data supports and re-enforces the need for your attention to the oral health of seniors:

Periodontal infections are more common in the elderly; about 23% of 65-74 year olds have several periodontal diseases;

About 30% of individuals 65 and older have lost all their teeth. However, statistics vary by state.

Studies have shown possible association between oral infections and systemic diseases such as diabetes, heart disease, and respiratory infections.

The incidence rate of oral and pharyngeal cancers is higher among seniors than for other age groups. Seniors who are 65 years and older are seven times more likely to be diagnosed with oral cancer than younger individuals.

Many seniors take medications that have the complicating side effect of reducing salivary flow (the amount and flow of saliva) resulting in xerostomia (or "dry mouth"). Reduction in salivary flow contributes to increased dental decay.

The vast majority of payment for dental services is out-of-pocket for older people. Medicare does not cover cost for oral health services and dental care, with only rare exceptions. For most people who have dental insurance coverage as a benefit of their employment, that coverage ends upon their retirement.

In addition, most seniors have limited income. This results in compromised access to dental care. Seniors are less likely to report having a dental visit in the past year. While 61% of the population reports having a dental visit in the past year; only 45% of seniors 75 years and older report having a dental visit.

Nursing homes and other long-term care facilities have limited capacity to deliver needed oral health services to their residents, most of whom are at increased risk for oral diseases.

In April, I released A National Call to Action to Promote Oral Health. This Call to Action was the result of a public-private partnership under the leadership of the Office of the Surgeon General that identified key actions that should be undertaken to improve our nation's oral health. As I noted in the Call to Action, "It is abundantly clear that these are not tasks that can be accomplished by any single agency, be it the federal government, state health agencies, or private organizations."

Changing perceptions of the public, health care providers, and others about oral health and its implications is one of the key actions. Some examples of steps that need to be taken include enhancing health literacy of our population, including oral health literacy; promoting interdisciplinary training of health professionals in counseling patients about how to reduce risk factors common to oral and general health; and training health care providers to conduct oral screenings as part of routine physical examinations and, when necessary, to make appropriate referrals.

Overcoming barriers to care by replicating effective programs is another important action step for improving the oral health of America's seniors. For example, HRSA's Bureau of Primary Health Care's Oral Health Program is specifically oriented to increasing access to oral health services. These programs support an oral health safety net for under-served populations, including the aging population. At this time there are 843 health center program grantees. 72% of the health centers provide preventive dental care onsite or by referral.

As always, building the science base is needed. CDC's Division of Oral Health provides substantial support for projects that examine the effectiveness of innovative strategies to promote oral health in predominately poor, ethnically diverse communities. Consistent with findings of recent reviews by the Task Force on Community Preventive Services and issues that I, as the Surgeon General, have raised, these projects are designed to address environments and behavior at multiple levels.

Projects that focus on older adults include: mobilizing community health advisors and changing care seeking behavior and oral health knowledge, attitudes and practices in rural Alabama (University of Alabama at Birmingham Center for Health Promotion); design, implementation, and evaluation of an oral health training program for nurses and home attendants caring for homebound elderly persons in Harlem (Columbia University Harlem Center for Health Promotion); and training elderly persons as oral health educators for children, an approach that could improve oral health among both age groups (University of Washington at Seattle Health Promotion Research Center).

In addition, NIH's National Institute of Dental and Craniofacial Research emphasizes the need to address health needs of the elderly. An ongoing clinical trial is looking at how multiple interventions can enhance oral health in the elderly (University of Washington). The purpose of this study is to test the effectiveness of a simple, low-cost intervention to reduce tooth loss in adults with a history of infrequent oral health care.

Finally, since oral health conditions are chronic and cumulative, investments in community-based, professional, and individual strategies to promote oral health across the lifespan will be of major benefit to improved oral health in the senior years.

In closing, let me summarize the goals of the National Call to Action to Promote Oral Health. They are:

To promote oral health;

To improve quality of life; and

To eliminate oral health disparities.

Sounds simple enough, but how do we get there? To begin, it will be up to those of you in this room to help make oral health care a part of health policy agendas. We must first educate the public, health professionals, and policymakers about the importance of oral health to general health and well-being at every stage of life. In addition, the oral health community must act to address the nation's overall health agenda.

The National Call to Action can be considered a "road map for oral health" — a guide for our efforts to improve oral health. The Call to Action asks for your response in 5 Action Areas:

Change Perceptions of Oral Health. We can no longer afford to have Americans believe oral health is separate from their general well-being. Improving the health literacy of the public, including oral health literacy, is key. Ensuring that other health professionals are knowledgeable about oral health is also important so that they can identify when a patient needs specific education or treatment related to oral health.

Replicate Effective Programs and Proven Efforts. As I've mentioned, many states have innovative programs through HRSA and under the research projects funded by NIH. The best practices must be recognized and replicated to help all seniors, in every state.

Build the Science Base. Biomedical and behavioral research will transform our knowledge of the prevention, diagnosis, and treatment of oral disease. But this knowledge must rapidly be turned into action for the public, providers, and community programs. We must ensure that the new science benefits all consumers, especially those who are in poorest oral health or at greatest risk.

Increase Oral Health Workforce Diversity, Capacity, and Flexibility. Women and minorities are underrepresented in the oral health professions, especially African Americans, Hispanics, and Native Americans. We should encourage diversity within the dental profession and culturally-competent messages as part of our effort to eliminate disparities.

Increase Collaborations. Disease prevention and health promotion campaigns that affect oral health — such as proper brushing and flossing and regular check-ups, as well as tobacco control and nutrition counseling — can lead to overall improved oral health for all Americans.

It is also important to remember that the prevention message that President Bush, Secretary Thompson, and I have been emphasizing all over America is as applicable for ensuring oral health as it is for avoiding other chronic conditions.

There are simple, small steps that any person can take can prevent dental diseases and improve their oral health:

Proper brushing and flossing;

Use of fluoride rinse or toothpaste;

Regular visits to the dentist;

Healthy eating;

Limiting alcohol use; and

Avoiding tobacco.

Tobacco use — whether cigarette, cigar, or smokeless tobacco —- can cause various forms of oral cancer. Less well known by the public, and even by many health professionals, is that cigarette smoking is responsible for half the cases of periodontal disease in the United States.

We need to get this information out to the public and to health professionals. Think of the many perspectives we have right here in this room, and the tremendous opportunity those perspectives represent for carrying the prevention message on oral health to every man, woman, and child in America.

As our elected leaders, you can help shape the debate on various levels to ensure that the oral health prevention perspective is heard. We are at a point in our nation's health history when we can really make a difference. Each and every one of us has the duty and responsibility to use the tools at our disposal to effect positive change. This change can come at the national level, it can come at the state level, it can come at the community level, and it can come in our own homes.

Today must be a day of change. Today must be a day when our work is a catalyst for better oral health for all Americans who need it. I thank you for your many efforts on behalf of senior's health, and I promise to work with you to improve the health and well-being of all Americans.